LANDSTUHL, Germany -- The dark gray military buses and ambulances arrive every day at the US medical center here, carrying soldiers wounded in Iraq.
One with bad shrapnel wounds; another unconscious, with burns over 60 percent of his body; still others with gunshot wounds, maimed limbs, open fractures, and spinal injuries. Some of the soldiers will be patched up well enough that they can return within a few weeks to their home bases, if not to their units in Iraq. But many face months of painful treatment at this facility in southwestern Germany and elsewhere before they can even go home.
"A lot of them will recover physically, but I have to say it will take them a long time to recover mentally," said Captain Paulette Smith-Kimble, an Army Reserve nurse assigned to the intensive care unit. "They are carrying a lot of baggage because of fallen soldiers who couldn't be saved or the fact that they can't go back [to their unit] . . . I have seen too many soldiers who lost limbs who can't go back," added the 34-year-old Boston native.
Seven months after President Bush declared the end of major combat operations in Iraq, the casualties keep on coming. The wounded often go unmentioned and unreported, their injuries overshadowed by news of soldiers killed as they went about jobs ranging from rooting out insurgents to patrolling neighborhoods and rebuilding schools and power grids.
As of Friday, the Pentagon reported 434 soldiers had died in Operation Iraqi Freedom, 298 of those in hostile attacks. But for every soldier killed in hostile action, nearly 10 have been wounded, according to official figures. Hundreds of the 2,094 wounded since the start of the conflict end up at the Landstuhl Regional Medical Center, the largest American hospital outside the United States.
The transfer of the injured from Iraq is a tightly run operation, with medical information sent ahead by computer and more highly specialized medical teams ready to be called in from the United States when necessary.
"Even before they take off we can see who is coming, what they need, and we can make all the plans even before they arrive," said Major Brent Johnson, a physician assigned to what the hospital calls its Deployed Warrior Medical Management Center.
For the wounded, this may be only their first stop on the way to a rehabilitation center or a hospital in the United States. Hospital officials said they try to keep stays down to two weeks. If patients cannot go back to duty by then, the goal is to move them to a treatment center near where they are based or near their families.
Specialist Guillermo Espinosa, 20, was brought to Landstuhl this month. He was just back from leave when the bus taking him to his unit in Kirkuk on Nov. 13 was hit by an explosive device. He was lucky; two others on the bus died.
"This time I was scared," said Espinosa, who received shrapnel wounds to his legs.
He would like to return to his unit, but because he cannot put any weight on his right leg he is "worthless," he said. Instead, he will be released soon to his home Army base in Vincenza, Italy.
In the buildup to the war, the number of hospital beds at the Landstuhl center was doubled to about 300, while 600 reservists were called in to help staff the hospital. During the past few months, the number of beds has returned to normal, while nearly half the reservists have been released. With the US military now more entrenched in Iraq, injured soldiers often can be treated there, reducing the number who need to be flown out for treatment. What has not changed, hospital staff members said, is the level of acute cases. The reliance of the insurgents in Iraq on improvised explosive devices -- including roadside bombs or mortars set off by remote control -- has meant a lot of messy, contaminated wounds and heavily injured limbs.
"We are seeing soldiers coming with missing eyes and limbs," said Major Cathy M. Martin, chief nurse of the intensive care unit. "You kind of develop a thick skin, but it still gets to you. It's never easy."